Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States An introduction for public heath, law enforcement, local organizations, and others striving to serve their community Authors: Jennifer J. Carroll, PhD, MPH; Traci C. Green, PhD, MSc; and Rita K. Noonan, PhD 2018 Contents Introduction and Overview ....................................1 Guiding Principles ................................................3 Evidence-Based Strategies ....................................7 Targeted Naloxone Distribution ............................................8 Medication-Assisted Treatment (MAT) ..............................10 Academic Detailing ..........................................................12 Eliminating Prior-Authorization Requirements for Medications for Opioid Use Disorder ............................14 Screening for Fentanyl in Routine Clinical Toxicology Testing ..............................................................16 911 Good Samaritan Laws ...............................................18 Naloxone Distribution in Treatment Centers and Criminal Justice Settings ............................................20 MAT in Criminal Justice Settings and Upon Release ..........22 Initiating Buprenorphine-based MAT in Emergency Departments ...............................................24 Syringe Services Programs ................................................26 References .........................................................29 Acknowledgements This document and its contents were reviewed by numerous subject matter experts. The authors would especially like to thank the following persons: Alice Asher, Grant Baldwin, Dita Broz, Deborah Dowell, Brian Edlin, Tamara M. Haegerich, John Halpin, Joann Yoon Kang, Reshma Mahendra, Philip Peters, Jessica Wolff, and Nick Zaller. Suggested Citation: Centers for Disease Control and Prevention. Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States. National Center for Injury Prevention and Control, Centers for Disease Control and Prevention, U.S. Department of Health and Human Services, 2018. Accessed [date] from http://www. cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf. Introduction and Overview Who is this document for? Based on these criteria, strategies identified can be considered promising or effective in reducing This document is to assist community leaders, opioid overdose. local and regional organizers, non-profit groups, law enforcement, public health, and members of the Over the course of several months, researchers, public in understanding and navigating effective public health professionals, and subject matter strategies to prevent opioid overdose in their experts were consulted to refine the list of strategies communities. considered into a collection of those interventions with the strongest evidence of efficacy AND with How can readers use this document? demonstrated feasibility in U.S. settings. These contributors, including physicians, epidemiologists, Readers can use this document as a general sociologists, medical anthropologists, harm reference for evidence-based practices that have reductionists, and more, offered individual input based been successfully implemented in the U.S. and are on their own research and experiences working at the effective in reducing rates of opioid overdose. This forefront of the opioid crisis. document also provides readers with straightforward This is not an exhaustive list of overdose prevention explanations of how and why these strategies work, strategies. Many countries—such as Canada, summaries of major research on these topics, Portugal, The Netherlands, Germany, Switzerland, and examples of organizations from across the Norway, Australia, and Uruguay, just to name a few— U.S. that have excelled at putting these strategies have implemented overdose-prevention policies and into practice. programs that have never been used in the U.S. Even within the U.S., many local organizers and advocates How was this document created? have developed unique, locally appropriate strategies too numerous to name here. The selection of evidence-based strategies included in this document began with a systematic search In sum, the strategies laid out in this document are of scientific literature on the prevention of opioid well known, evidence-based actions that U.S. states overdose in the context of prescription opioid and municipalities can take today to prevent new misuse or use of illicit opioids. To be considered overdoses tomorrow. for inclusion in this document, strategies must have been successfully implemented in at least Why evidence-based? one jurisdiction in the U.S. as evidence for this document was being reviewed (between Opioid use disorders and opioid overdose are complex April and August 2017) AND meet one of the phenomena shaped by numerous social, biological, following evidentiary criteria: (1) meta-analyses and psychological factors. Due to this complexity— or systematic reviews have found the strategy to and the natural complexity of all human beings—fully be effective at reducing overdose and/or factors understanding and accounting for all of these factors that increase overdose risk; (2) evidence from a in an overdose prevention activity is a significant scientifically rigorous experimental study, such challenge. Often, ideas that once looked promising fail as a randomized controlled trial, demonstrates to pan out as expected.* There are also strategies the strategy’s effectiveness in reducing overdose that at first glance appeared counter-intuitive or and/or factors that increase overdose risk; or (3) wrong but were ultimately shown to be very effective multiple observational studies from U.S. settings in preventing fatal overdose. Subjecting overdose indicate the strategy’s ability to reduce overdose or prevention interventions to scientific testing and mitigate and reduce factors that increase overdose evaluation is the only way to know for sure whether risk. In order to provide the broadest possible these intuitions are correct. scope of evidence for guiding the implementation of In acknowledgement of this pressing need, a overdose prevention strategies in the U.S., research practice is considered both “locally appropriate” that has been conducted in international settings and “evidence-based” if it has been designed in that examines strategies also well-studied and accordance with three key sources of information: proven feasible in U.S. settings are included in this (1) high quality scientific research; (2) the document as well. professional opinions and experiences of clinical Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 1 and public health experts; and (3) the preferences, priorities, and values of the individuals who will be targeted or affected by that practice.1 By offering this summary of the current “best practices” for overdose prevention, based on a thorough review of existing research and expertise from a diverse array of medical and public health professionals, this document aims to fulfill areas 1 (scientific research) and 2 (expert opinions). Area 3, the preferences and priorities of those affected (in this case, individuals who use opioids or are otherwise at risk of opioid overdose), must be sought anew in each new community context. This combination of evidence, expertise, and community dialog will lay the groundwork for truly effective opioid overdose prevention strategies across the U.S. * Research shows that some opioid use and overdose prevention interventions have harmful effects on individuals at risk. Some have even been shown to increase the risks of opioid overdose. The causes of these harms often include the sharp reduction of opioid tolerance during periods of high risk for relapse; the inadvertent promotion of riskier drug use practices through inattention to structural risk factors; and the exposure of at-risk individuals to additional trauma. Examples of strategies shown ineffective by research and data include: arrest and incarceration, compulsory treatment, rapid detox without opioid agonist/antagonist medication assistance, inappropriately implemented school-based education (e.g. short sessions focused on knowledge improvement and resistance only, mixing students from different risk groups), and inappropriately implemented drug court systems (e.g. low quality service provision, improper participant selection, lack of program evaluation). 2 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control Guiding Principles Below are four overarching principles, lessons gleaned from previous public health emergencies, such as the HIV/AIDS crisis in the 1980s and 1990s. These principles serve as a guide for the design and implementation of effective overdose prevention strategies. 1. Know your epidemic, know your response those players take on those roles in deliberate coordination with each other. Accomplishing First advanced by UNAIDS as a guiding principle this requires much more than sharing data and for global HIV prevention and control, the mantra intelligence. The implementation of a proven public “know your epidemic, know your response” health approach such as a 911 Good Samaritan originally spoke to the mismatch between strategy Law may be ineffective if law enforcement officers and reality that hindered HIV control efforts in are not included in the planning and design of its the first years of